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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ~ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED. <br /> (Complete in Triplicate) <br /> Application is hereby made to $an Joaquin Count for <br /> application is made in c y permit to construct and/or insta <br /> omplianwith Ban Joaquin County Ordinance ll the work heroin described. This <br /> No. 54 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ices. <br /> 4 <br /> � Job Address <br /> City Lot Size/Acreage <br /> Owner's Name Address 4 <br /> Phone <br /> Contractor Addrescense Ns .` <br /> TYPE OF WELL UM ff� Phone <br /> N WELL ❑ WELL REPLACEMEN E DESTRUCTION ❑ Out of Service We11 Cl <br /> PUMP! INSTALLATION SYSTEM REPgI ❑ OTHER ❑ ., Monitoring well <br /> DISTANCE 70 NEAREST: SEPTIC TANK `'-SfWER-I:INES-^---�--w =-- � � �� <br /> -DlSPQSAL,fLD. PRDP. LIN€ �\ <br /> 1 FOUNDATION AGRICULTURE WELL OTHER VII€LL PITS/SUMPS [ _' <br /> INTENDED`USE( `_ TYPE-OF-WELL-�-,-PROBLEM-A-REA�CONSTRUCTION SPECIFICATIONSr- -.� <br /> f C1 Industrial I , O Open Bottom ❑ Manteca Dia. of Well Excavation ! <br /> fa Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> ,.i Type of Casing_ Specifications <br /> I') Public Cl Other Depth of Gr6ut Seat <br /> Cl f � Delta Type of Grout <br /> ! I Irrigation ;t'"' Approx. Dept 1 ) Eastern <br /> j r ace Sea! Installed by <br /> Repair Work Done L7� Type of Pump H.P. / � � <br /> Well Destruction #_ ' 1 !t State,Work Done <br /> rO Wel! piameter -- -.Sealing.Ma erial & Depth ' d`i <br /> � <br /> ;rt , Depth ,' -� Filler Material b Depth�°,, <br /> TYPE OF SEPTIC WORK: MEW INSTALLATION II] :111: p <br /> CR I I DESTRUCTION I ! itJo septic system permitted if public sewer is <br /> Installation will se <br /> r ! � J wf available within 200 feet.) <br /> ✓ <br /> ser 'e:/Residence Commercial.�„,-Other I <br /> Number �- <br /> of living units:! .- _Number of bedrooms <br /> Character of soil to a depth of 3 feet: -) �.4 a— -- <br /> SEPTIC TANK. tri ❑ r Type/Mfg �A�� <br /> PKG. TREATMENT PL-T�❑ Capacity_ <br /> i Distance to nearer;: Well Foundation <br /> LEACHING LINE SAN JOAQUIN COIJI' 'Ty <br /> L�1 Na. & Length of linea Total IQQ HEAL tri <br /> FILTER BED ❑ Distance to nearest: Well �,ENK <br /> Foundation y ine <br /> SEEPAGE PITS i I I Depth Size <br /> ( Number <br /> SUMPS }} <br /> ❑0 Distance to nearest: Well <br /> DISPOSAL PONDS 1 Foundation property.Line . <br /> „. <br /> hat <br /> thereby certify tions have.prepaced this_applicationzand- hai_tfie_work-will be-done.in.accordanc"i(K� Sam foaquin.co_unt ordinances,,atata lbws and <br /> rules and regulations of the San Joaquin County -�- _ Y <br /> Norm)'owner or licensed agent's signature certifies the following: "I certify that in the <br /> shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Californiance of ."Contrawork ctowhich hring orr sub-cont act nglsignature <br /> certifies the following:. I certify that in tbe performance of the work for which this permit is issued, I <br /> tion laws of California." t shall employ persons subject to workman's companaa- <br /> The applica t s 'R for a req ins ions. Complete drawing on rev side. <br /> Signed <br /> Title: <br /> ' Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Acceptedby Dare <br /> I <br /> � � ! Area <br /> Pit dr�Grout,lnspectioby; Date <br /> \ s Final Inspection by <br /> Additional Comments <br /> 1 [ I <br /> Applicant - Return all copies to: San Joaquin Coanty Public Health Services i <br /> E <br /> Environmental Health Permit/Services ' <br /> 1 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> INFO i4MOUNT.RtJE _ AMOUNT REMITTED (CK IiECE1VED 8Y .� <br /> _ CASH`:^, ,, lam^ �DATE— <br /> EN <br /> ATE EH 13.24{NEY:t/•M SI — -- j�-- ff V�. �.I I <br /> EH 11.26 <br />